San Francisco Chronicle - Friday, September 22, 2006
Sabin Russell, Chronicle Medical Writer

Three years in the making, the new guidelines released by the Centers for Disease Control and Prevention in Atlanta call for making AIDS testing for patients ages 13 to 64 as routine as leaving a urine sample at the doctor's office.

If the recommendations are carried out by doctors and patients, all Americans from teens to aging Baby Boomers eventually would take at least one test to see if they carry antibodies to HIV, the virus that causes AIDS.

The guidelines are a significant break from nearly two decades of HIV policy, in which the emphasis has been on testing primarily those deemed to be at highest risk.

The HIV screening would remain voluntary, but instead of asking patients if they would like to take the test, doctors would tell patients they will be tested unless they say no. In the parlance of HIV prevention, the process is called opt-out testing.

To streamline the process and remove perceived barriers to testing, the CDC recommends dropping pretest counseling sessions typically provided before a patient takes an HIV test. A requirement for a separate consent form would be dropped.

"We are excited to be able to take a new step in a new direction," CDC director Dr. Julie Gerberding said during a telephone press conference. She said traditional approaches were not successful in spotting the hidden cases of HIV infection -- one reason an estimated 40,000 Americans still come down with the virus each year.

Estimates are that nearly 1 million Americans are living with HIV but that a quarter of them do not know it because they have never been tested.

Patients whose HIV infections are detected early respond better to medical treatment than those who find out only when their immune systems have started to collapse, perhaps 10 years after they contract the virus. It is also much less expensive to treat HIV before a patient develops the symptoms of AIDS. In the meantime, those unaware of their HIV infections are 3.5 times more likely than patients who know they are positive to transmit the virus to someone else.

Gerberding said nearly 40 percent of HIV diagnoses today are made less than a year before those patients develop AIDS -- clear evidence that the testing has come too late.

At about $12 per test, the expanded HIV screening could cost billions. The CDC recommendations do not address how to pay for such an undertaking, and they are being made just as Congress is preparing to cut millions of dollars for AIDS treatment and care programs in hard-hit cities such as New York, San Francisco and Los Angeles.

Much of the burden for the new testing program would fall on private insurers, but CDC officials maintain that the money saved by early diagnosis makes it a wise investment. Blue Cross of California spokesman Robert Alaniz said cost won't be an issue. "We'll pay for the tests," he said.

In addition to its call for widespread, routine testing, the new CDC recommendations seek additional tests for pregnant women in 22 states and the District of Columbia, where the highest levels of HIV-positive prenatal results are found. California is not among them.

The guidelines call for routine testing to begin with children as early as age 13 and a repeat test at least annually for anyone who has more than one sexual partner since their last screening. In California, laws permit teens to be tested for HIV without the knowledge or consent of their parents.

Among the places where the CDC wants HIV testing to become routine are in crowded emergency rooms, where much of the impoverished population of the United States seeks medical care. A pilot program offering free testing -- with written consent -- has been under way since January 2005 at Highland Hospital in Oakland.

The program uses oral HIV tests, which provide preliminary results in 20 minutes. "We've tested over 8,000 people, and found 101 new HIV-positive patients," said Highland emergency room physician Dr. Douglas White. "Our project exceeded my expectations."

Many of the newly diagnosed patients were people who would not ordinarily have been offered testing aimed at perceived high-risk groups, he said. Nearly 9 out of 10 of these HIV-positive patients were directed to treatment and care programs, he added. White said those remaining patients, often homeless or drug abusers, are "incredibly hard to track down."

At Kaiser Permanente in Northern California, executives are studying the new recommendations, and contemplating the enormous task ahead of them. "We have the capacity, but it is a lot of work. That is a lot of testing to be done," said Robert Allerton, who directs HIV policy for the Permanente Medical Group. "But no one would disagree that more testing has to be done, and sooner."

Northern California Kaiser has 2.3 million members aged 13-64, and about 104,000 of them received at least one HIV test last year. Allerton said the current testing program includes extensive pretest and post-test counseling, and he believes those sessions provide valuable prevention education. "We're certainly not going to throw away our pretest counseling," he said.

Despite the hopes of policymakers that routine HIV testing will reduce the stigma surrounding AIDS, Allerton cautioned that important distinctions should not be glossed over. "No one is ever fired from their job for having high cholesterol. Nobody got divorced because of a cholesterol test," he said.

Bebe Anderson, HIV project director for Lambda Legal, a New York civil rights organization focused on gay issues, said pretest counseling was still essential. "With these revised recommendations, the CDC is shirking its responsibility to persons tested for HIV and missing an important opportunity to improve prevention and treatment of HIV infection."

Walt Senterfitt, chairman of the board of the Community HIV/AIDS Mobilization Project of Providence, R.I., said that the recommendations give short shrift to post-test counseling for those who are negative. "A negative test may be misinterpreted," he said, leading a young man to think risky sexual behavior isn't so risky after all. "It may be just a spin of the roulette wheel, and you can come up positive next time around."

But his primary concern is that the testing program may come at the expense of other HIV prevention and treatment efforts. "Where's the money for this going to come from?" he asked.

Mark Cloutier, executive director of the San Francisco AIDS Foundation, welcomed the new CDC guidelines as an important step toward "normalizing" HIV as an identifiable and treatable disease. "It is the right strategy," he said.

He also lauded the recognition in the CDC policy that patients who test positive should be given access to care and treatment. But he remains concerned that Congress, in the reauthorization of the Ryan White CARE Act, may strip as much as $29.6 million from San Francisco's allotment during the next five years.

Much of the money lost to the large urban epicenters of the AIDS epidemic would be directed to the South, where HIV infection rates are rising fastest. "It is robbing Peter to pay Paul," Cloutier said. "It harms one group to help another."

E-mail Sabin Russell at srussell@sfchronicle.com.
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